Hirsh H L
J Fam Pract. 1975 Jun;2(3):213-6.
This article discussed the physician's obligations in record-keeping and current judicial attitude towards the patient's medical record. Physicians are required, both medically and legally, to maintain a current, adequate record for each patient. This established the physician's continuity of care, but it also requires his vigilance and diligence through constant review and surveillance. In the past, the record was exclusively the property of the health care provider. Of late, jurisdictions are decreeing that the health care provider has an absolute right to possession and ownership of the original record only, and the right to the information in the record belongs absolutely to the patient. The physician is liable for the proper maintenance, custody, and storage of the record for the required statutory period. Although the patient can custimarily obtain his record by court order, the courts have also recognized the concept of professional discretion under which a physician may deny the patient access to his medical record if in the physician's judgment he believes it would be to the patient's detriment.
本文讨论了医生在病历记录方面的义务以及当前司法界对患者病历的态度。从医学和法律角度而言，医生都必须为每位患者保存一份最新、完整的病历。这确立了医生持续的护理责任，但同时也要求医生通过持续审查和监督保持警惕并勤勉尽责。过去，病历完全是医疗服务提供者的财产。近来，各司法管辖区规定，医疗服务提供者仅对原始病历拥有绝对的占有权和所有权，而病历中信息的权利则绝对属于患者。医生有责任在法定要求的期限内妥善维护、保管和存储病历。虽然患者通常可以通过法院命令获取其病历，但法院也认可专业酌处权的概念，即在医生判断认为提供病历会对患者造成损害时，医生可以拒绝患者查阅其病历。
